U.S. Policy, Ideology and the HIV Epidemic: Undermining Effective Prevention Strategies

Presentation for the Working Group on U.S. AIDS Policy
Jodi Jacobson
Executive Director of Center for Health and Gender Equity (CHANGE)

Introduction by Joseph O’Reilly (International HIV/AIDS Alliance)
For organisations not receiving USAID money, US conditionality may not be a central policy issue. For organisations which are, it may be difficult for them to speak out. There is therefore a need for an advocating mechanism which is not dependent on organisational leadership or endorsement. This Working Group would aim to be this mechanism and membership is open to individuals here tonight.
Hearing from Jodi Jacobson tonight about her perspective on the impact of U.S. AIDS Policy on HIV Prevention Programs globally will inform the work this group does.

Presentation by Jodi Jacobson (CHANGE)
“CHANGE is a U.S.-based non-governmental organization focused on the effects of U.S. international policies on the health and rights of women, girls, and other vulnerable populations in Africa, Asia, and Latin America. CHANGE believe that every individual has the right to the basic information, technologies, and services needed to enjoy a healthy and safe sexual and reproductive life free from coercion and preventable illness.
Their mandate is based on the premise that it is the responsibility of US organizations, connected to US constituencies, to foster accountability of our government's policies abroad. Their overarching goal therefore is to ensure that U.S. international policies and programs promote sexual and reproductive rights and health through effective, evidence-based approaches to prevention and treatment of critical reproductive and sexual health concerns, and through increased funding for critical programs.”

CHANGE was founded in 1994 and aims to:
- Advocate for effective policy
- Monitor funding streams set by Congress
- Examine operational aspects at ground-level

What are the problems we are trying to solve?
- 5 million new infections
- Vast majority without access to treatment
- Women increasingly the majority of those infected and majority are sexually active
- 80% of new infections in South Africa are sexually transmitted

What is the ultimate goal?
- Safe, happy, consensual sex for all
- Prevention of disease
- Reduction of risk

PEPFAR and its funding streams
The President's Emergency Plan for AIDS Relief (PEPFAR) is a U.S. five year $15 billion global initiative to combat the HIV/AIDS epidemic, given over a period of 5 years – in theory. It aims to treat 2 million, provide care and support for 10 million, and prevent 7 million. Aid goes to 15 focus countries (11 of which are in Africa, 4 in the Caribbean, and lastly, Vietnam) and 85 non-focus countries. There is the mistaken conception that U.S. conditionality only affects the 15 focus countries. This is not true – all these countries are affected.
In theory, $9 billion is going to U.S. bilateral HIV/AIDS programs in 15 countries, $5 billion to the other 85 countries and $1 billion to the Global Fund.
In practice, this has not happened. For example, $550 million has gone to the Office of the Global AIDS Coordinator (OGAC), funds which are unaccounted for. $253 million has been spent on treatment and $233 million on prevention,

Conditions and Conditionalities
Some of these e.g. “ABC” and the Prostitution Loyalty Oath are derived from law. Others are not e.g. shifts in condom funding and distribution, rejection of hard reduction strategies. These were policy decisions made by OGAC.

1. “ABC” as a conditionality
OGAC deemed that 33% of funds which are spent on Prevention should be put towards Abstinence Until Marriage programs. Incidentally, this not considered a requirement until FY2004.
Problems:
- 33% of what?
- What is Prevention exactly?
- Abstinence Until Marriage has been interpreted as Abstinence Only Until Marriage.
- There is disaggregation of prevention programs i.e. Adolescents receiving Abstinence Only, Married Couples receiving Be Faithful and High Risk Individuals (e.g. Sex Workers) receiving Condom Use. There is no comprehensive Prevention Program.
- In-country levels can be higher than 33% e.g. in Uganda (where 60% of young people are HIV-positive).

2. Shifts in condom procurement, distribution and messaging
- The overall budget for condoms under PEPFAR has not increased.
- In 2004, fewer condoms were distributed to focus countries than in the previous year.
- Female condoms are not being talked about, supported or scaled up.
- U.S. Policy on condoms is reducing their availability to the groups most in need.
- FY2006: only 2 focus countries included condoms in their HIV/AIDS program description (Ethiopia and Mozambique).

3. Prostitution Loyalty Oath
This denies funding to organisations that refuse to sign a pledge stating that they do not support promotion or legalisation of prostitution. Although some organisations e.g. Christian Aid have managed to word their pledges in a way which still allows them to provide care for sex workers (by stating that although they do not support promotion of prostitution, they will provide care for vulnerable populations, including sex workers) this is an example of a bad law, made into even worse policy:
- What is opposing prostitution?
- Does providing English classes to Cambodian sex workers mean you are supporting prostitution? An organisation in this very situation withdrew their classes because of fears of losing USAID funding.
Both the law and policy are unclear and place unnecessary restrictions on organisations working to combat the HIV epidemic.

4. Global Gag Rule
“Its restrictions mandate that no U.S. family planning assistance can be provided to foreign NGOs that use funding from any other source to: perform abortions in cases other than a threat to the woman’s life, rape or incest; provide counselling and referral for abortion; or lobby to make abortion legal or more available in their country.”
It undermines the very basis of reproductive and sexual health programs. For example, in Kenya, organisations receiving funding from PEPFAR took away staff from Kenyan family planning groups (who could not pay as high salaries). In Peru, organisations receiving funding from PEPFAR were told that they could not give information on emergency contraception.
With the recent absorption of USAID in the State Department, the Global Gag Rule could then apply to all State programs.

Barriers
- No effective opposition to the ‘Far Right’ in the U.S. (“the Democrats are MIA in the U.S.!”).
- There is lack of communication between AIDS advocates and Sexual and Reproductive Health advocates (“as far as women are concerned, they are the same thing”).
- Some organisations took money thinking that they could “fix it later”. They didn’t.
- Not enough mobilisation of U.S. Constituencies
- Not enough focus on Monitoring & Accountability at U.S. and In-Country level

Solutions
- Working together
- Sharing information
- Getting ‘Voices from the Field’
- Working to get the E.U. to speak out on Prevention

General Discussion
A summary of comments from the floor:
- U.S. AIDS Policy is ideology-based, not evidence-based, meaning that AIDS advocates can only get so far.
- Reaching U.S. Constituencies and State-level Programs with effective information is vital. “With good information, most reasonable people can be convinced.”
- Advocates in the UK should be calling for stronger leadership from minsters/civil servants e.g. stating the importance of harm reduction, E.U. advocating comprehensive prevention programs
- DFID – although unlikely to oppose U.S. AIDS policy, how about a statement stating that DFID does not support programs that give misinformation e.g. about condoms?
- New Partners Initiative (where U.S. giving funding to organisations which have only received a certain amount of funding in the past and have not been involved with Condom Promotion activities; most of these are Faith-Based Organisations) has nothing to do with AIDS programs, but is a way to channel funds into an area in order to increase its capacity, namely that of Faith-Based Organisations. Are the funds going to these organisations actually being used for Abstinence Programs? In fact, much of the funds do not even leave the U.S.
- Need to define what a comprehensive program is.